2019 Aminoglycoside Competency - Summit

Trainee: Schlobohm, Cory (submitted 2019-09-04 19:43:51)
Trainer: Miyazawa, Yuumi (submitted 2019-09-06 17:04:37)
Manager: Miyazawa, Yuumi (submitted 2019-09-06 17:04:58)
Status: Completed
Result: Pass

Population Pharmacokinetics

Criteria
Trainee Response
Trainee Notes
Trainer Response
Trainer Notes
JD is a 73 year old male (Wt 80 kg, Ht 72 in) being treated for a prosthetic valve endocarditis caused by methicillin-sensitive Staphylococcus aureus (MSSA) and is being followed by an infectious diseases physician. He has a normal WBC, been afebrile, and SCr is stable at 1.3 mg/dL. The ID physician would like to treat the patient using combination therapy and ordered nafcillin, rifampin, and gentamicin dosed per pharmacy for synergy.

Using the case above, calculate the aminoglycoside clearance (ClAg).
 
A. 49 mL/min
 
B. 57 mL/min
 
C. 63 mL/min
 
D. 87 mL/min
Pass
Fail
Calculate volume of distribution (Vd).
 
A. 20 L
 
B. 28 L
 
C. 32 L
 
D. 56 L
Pass
Fail
Calculate elimination rate constant (k) and half-life (t1/2).
 
A. K = 1.71 hr-1, half-life (t1/2) = 4 hr
 
B. K = 0.271 hr-1, half-life (t1/2) = 2.5 hr
 
C. K = 2.85 hr-1, half-life (t1/2) = 0.2 hr
 
D. K = 0.172 hr-1, half-life (t1/2) = 4 hr
Pass
Fail
What is the goal gentamicin level?
 
A. Peak = 10-24 mcg/mL
 
B. Peak 5-10 mcg/mL
 
C. Trough < 1 mcg/mL
 
D. Trough < 2 mcg/mL
Pass
Fail
What is an appropriate starting dosing regimen?
 
A. 240 mg IV q24h
 
B. 120 mg IV q12h
 
C. 80 mg IV q12h
 
D. 80 mg IV q24h
 
E. 80 mg IV q8h
 
F. 400 mg IV q24h
Pass
Fail
What is the predicted (calculated) trough level? Assume the trough will be drawn 30 minutes prior to the 3rd dose.
 
A. 1 mg/L
 
B. 0.6 mg/L
 
C. 0.1 mg/L
 
D. 2 mg/L
Pass
Fail
Case continued: JD was started on nafcillin 2gm q4h, rifampin 300 mg PO q8h, and the gentamicin dosing regimen from question 1. Today is day 2 on this antibiotic regimen and the gentamicin trough resulted (drawn appropriately, 30 minutes prior to the next dose): 2.0 mcg/mL. SCr is 1.9 mg/dL today. The next dose has not been hung yet.

What would be an appropriate next step?
 
A. Hold next dose and check a random level
 
B. Increase dose and extend frequency
 
C. Decrease dose and keep same frequency
 
D. Keep same dose and decrease frequency
Pass
Fail
What is the appropriate follow-up monitoring and frequency for this patient?
 
A. SCr daily until renal function is stable
 
B. Repeat 8-hour post-dose random level with new maintenance dose when renal function is stable
 
C. Repeat trough level with new maintenance dose when renal function is stable
 
D. Review addition of nephrotoxic agents every 3 days
 
E. A, C
 
F. A, B, D
 
G. All of the above
Pass
Fail

Aminoglycoside Dosing

Criteria
Trainee Response
Trainee Notes
Trainer Response
Trainer Notes
WG is a 67 year old female (Wt 69 kg, Ht 61in), admitted for sepsis and febrile neutropenia. The patient was found to be hemodynamically unstable and has a history of urosepsis from multi-drug resistant organisms. The patient was started on vancomycin IV, meropenem, and tobramycin per pharmacy. The BUN/SCr is 12/0.5 and urine output is 70-80 mL/hr

What dosing regimen would be appropriate?
 
A. 350 mg IV x 1
 
B. 280 mg IV x 1
 
C. 110 mg IV x 1
 
D. 80 mg IV q12h
Pass
Fail
The first dose was given was on 6/29/19 at 0930. When would levels be ordered?
 
A. Trough level before the 2nd dose, on 6/30/19 at 0900
 
B. Peak level 30 minutes after the 1st dose, on 6/29/19 at 1100
 
C. Random level 8 hours after the end of the 1st dose, on 6/29/19 at 1830
 
D. Random level 24 hours after the end of the 1st dose, on 6/30/19 at 1030
Pass
Fail
A random tobramycin level obtained 12 hours after the end of the infusion of the first dose results in a serum concentration of 8.0 mcg/mL. What is the appropriate next step?
 
A. Repeat random level 8 hours after the end of the infusion of the 2nd dose
 
B. Enter maintenance order for every 24 hours (keep dose same as 1st dose)
 
C. Enter maintenance order for every 24 hours (reduce dose from 1st dose)
 
D. Enter maintenance order for every 48 hours (keep dose same as 1st dose)
Pass
Fail
WG is started on a maintenance dose of tobramycin that you have entered. She is on Day #4 of tobramycin and had a CT abdomen/pelvis with IV contrast yesterday. Urine culture is growing MDR Klebsiella pneumoniae only sensitive to aminoglycosides. The SCr/BUN is 30/0.9 and UOP is 30-40 mL/hr. What is the appropriate next step?
 
A. Continue same dose and repeat random level 8 hours after the next dose
 
B. Check peak level two hours after next dose
 
C. Obtain trough prior to next dose, hold next dose until trough level results
 
D. Repeat random level 24 hours after the next dose
Pass
Fail

Hemodialysis

Criteria
Trainee Response
Trainee Notes
Trainer Response
Trainer Notes
OB is a 45-year old male (Wt 91 kg, Ht 64 in) who has ESRD on hemodialysis and admitted to the medical floor after experiencing shortness of breath and becoming hypotensive during an outpatient dialysis session. In the E.D., he was found to have a left lower lobe infiltrate seen on the chest X-ray and was diagnosed with pneumonia. The physician ordered a sputum culture and started him on piperacillin-tazobactam.

On day 3 of therapy, the sputum culture grew Pseudomonas aeruginosa. The patient was not clinically improving on the current antibiotic therapy, so the physician ordered tobramycin per pharmacy dosing protocol. The patient?s BUN/SCr is 39/4.2 mg/dL and WBC is 17 K/uL.

Calculate IBW, DBW, and Vd.
 
A. IBW = 54 kg , DBW = 72 kg, Vd = 25 L
 
B. IBW = 59 kg, DBW = 72 kg, Vd = 25 L
 
C. IBW = 59 kg, DBW = 72 kg, Vd = 27 L
 
D. IBW = 54 kg, DBW = 59 kg, Vd = 32 L
Pass
Fail
Calculate the loading dose.
 
A. 200 mg x1
 
B. 140 mg x1
 
C. 100 mg x1
 
D. 70 mg x1
Pass
Fail
The loading dose you calculated has been given to the patient. The patient is scheduled for a dialysis session later this evening. When would it be appropriate to draw tobramycin levels relative to the loading dose?
 
A. 2 hours after the loading dose
 
B. 2 hours after hemodialysis ends
 
C. Next AM labs
 
D. A, B
 
E. A, C
Pass
Fail
A pre-dialysis level Wednesday morning results in a tobramycin level of 1.8 mg/L. Patient is on a MWF dialysis schedule. What is the plan for supplemental dosing?
 
A. Hold dose for today, re-check level with next AM labs
 
B. Give 70 mg x1 post-HD today
 
C. Give 140 mg x1 post-HD today
 
D. Give 180 mg x1 post-HD today
Pass
Fail

Acknowledge

This training has been acknowledged